Tag Archives: Substance dependence and addictions

Substance Abuse & Addictions

The impact of legalized marijuana on professional counseling

By Bethany Bray March 30, 2022

In 1996, California voters passed Proposition 215, making the Golden State the first in the U.S. to legalize the use of medical marijuana.

Two decades later, the medical use of cannabis is legal in 37 states, Washington, D.C., and the territories of Guam, Puerto Rico and the U.S. Virgin Islands. Additionally, 18 states, Washington, D.C., and two territories have enacted legislation to regulate cannabis for nonmedical (i.e., recreational) uses, according to the National Conference of State Legislatures. Just three states — Kansas, Nebraska and Idaho — do not allow public access to cannabis in any form, medical or otherwise.

In states where cannabis use has been legalized, many medical and mental health practitioners have found it necessary to shift their mindset — from viewing marijuana as an illegal substance to something that medical doctors can condone or even recommend and that potentially has benefits for a range of conditions, including chronic pain and posttraumatic stress disorder (PTSD).

“When it was first becoming legalized, it was a bit of a panic for the [addictions] treatment community around ‘How are we going to deal with this?’ What has evolved is that now, it’s viewed in a similar way as alcohol is: There is a continuum of users, [and] it can be abused but also used socially or occasionally,” says Adrianne Trogden, a licensed professional counselor and supervisor (LPC-S) and licensed addiction counselor (LAC) with a private practice in New Orleans. “It’s a hard transition for treatment providers to go from thinking of it as an illegal street drug to being dispensed as a medicinal medication. … In treatment facilities, you see the worst of the worst — those whose lives have been ruined by substance. It’s easy to see the ugly side of addiction and naturally be leery of [marijuana] being used for medicinal use. That mindset is hard to shift.”

Legalization has also meant that professional counselors cannot keep their heads in the sand about this issue, regardless of how they feel personally about the use of marijuana, says Paula Britton, a licensed professional clinical counselor and supervisor with a private practice in Cleveland. Practitioners need to be comfortable broaching the subject of how and why a client uses marijuana, and they should be familiar with the pros and cons of the substance as it relates to adult mental health and wellness. In addition, they should understand the nuances of cannabis regulation in their state.

At the same time, counselors must know how to assess clients for cannabis use disorder and listen for indicators that an individual may be drug seeking, Britton says.

Talking about clients’ marijuana use “gets tricky,” admits Britton, who is licensed as both a counselor and a psychologist. “Because of that, many counselors don’t want to get involved or learn about it. But I don’t know if we’re going to have that option in the years to come” as it becomes increasingly legalized. “We have to be aware that this is going on and that [marijuana use] is helpful for some people,” she continues. “We have to acknowledge that our clients are using it, or wanting to use it, for medical or recreational purposes and [consider] what … that mean[s] for us in counseling.”

Mixed messages

Cannabis is classified as a Schedule 1 substance under the Controlled Substances Act, which makes its distribution a federal offense. This puts marijuana alongside heroin, ecstasy, LSD and other substances that are “defined as drugs with no currently accepted medical use and a high potential for abuse,” according to the U.S. Drug Enforcement Administration.

This sends a confusing and mixed message, both to the public and to health professionals, given that marijuana may be legal and OK to use at the state level yet illegal federally, Britton says. In addition, the complicated regulatory scheme has impeded much-needed research on the effects marijuana can have on a range of conditions when used in a controlled, medically sanctioned way.

In the meantime, counselors must rely on the limited research that has been done by other disciplines or by researchers outside of the country. The few studies that have been done have yielded mixed results on marijuana’s efficacy for mental health diagnoses, particularly anxiety and depression, Britton notes.

“There’s just so much we don’t know,” says Britton, a professor of clinical mental health counseling at John Carroll University. “If we [counselors] are going to be evidence based, it’s hard to have an informed decision about what you think without that [research] behind you.”

One example of the mixed messaging surrounding cannabis use involves the U.S. Department of Veterans Affairs (VA). The VA has done studies that show medical marijuana can help individuals with PTSD, yet it will not endorse its use for VA patients because of the federal law, Britton notes.

The American Psychiatric Association issued a position statement in 2019 saying that it would not endorse the use of medical cannabis for the treatment of PTSD “because of the lack of any credible studies demonstrating [its] clinical effectiveness.”

Aaron Norton, a licensed mental health counselor, licensed marriage and family therapist and certified rehabilitation counselor with a private practice in Largo, Florida, suggests that the mixed data regarding marijuana use allows people who argue either for or against its legalization to cherry-pick studies that support their view. Some people, for example, have cited reports linking the legalization of medicinal cannabis with lower opioid overdose mortality rates as evidence that medical marijuana is the answer to ending America’s opioid epidemic.

“What I am concerned about is the touting of medical cannabis as the cure-all magical wonder drug,” says Norton, who has written and presented on legalized marijuana’s impact on the counseling profession. “There is contradictory evidence out there … [and] overall there’s very little evidence that medical marijuana helps many of the things that we think it does. I’m concerned about the claims that are made and [the] use of it in mental health treatment.”

It is well-known, however, that marijuana use can have a negative impact on child and adolescent brain development and has also been tied to lung problems (when used in inhaled forms) and other challenges later in life, Britton says. She advises counselors to also be mindful that marijuana use can affect the efficacy of psychotropic medications such as antidepressants that are commonly used by clients. 

Even when used legally, marijuana can still have adverse effects on clients’ employment, particularly if they work for the federal government or in fields that require regular drug testing. Marijuana stays in the human body and can show up on drug tests weeks after a person uses it, notes Britton, who co-authored a recent Journal of Counselor Practice article on Ohio mental health professionals’ attitudes, knowledge and experience regarding medical marijuana.

This aspect of marijuana use also has implications for counselors who work in the field of substance use because it can be difficult to determine an individual’s length of abstinence, says Trogden, an assistant professor in the counseling department at the University of the Cumberlands.

Dosing concerns

Dosing is another potential area of confusion related to legalized marijuana for individual users and health professionals.

Norton says that in Florida, it is mostly left up to the individual to purchase and use whatever dose they believe is best — a situation he labels a “free-for-all.” Physicians in Florida do not prescribe specific doses to patients who are granted a medical marijuana card because it remains illegal federally, he explains.

Similarly, Britton points out that employees at marijuana dispensaries in Ohio are not doctors and will often sell customers whatever dosing amount they request. Determining the correct cannabis dosing is complicated because the “optimal dose” will be different for every person, she says. The same amount of substance will affect people differently depending on whether it is inhaled or eaten, such as in gummy candy or baked goods. 

Matthew McClain, a school counselor in Fort Morgan, a small town in northeast Colorado, notes that dosing is a concern for youth because they often won’t read or adhere to the instructions or labeling for items that have come from a cannabis dispensary. For example, a teenager may open a marijuana brownie or piece of cake and eat the entire thing without pausing to read or acknowledge that it may be equal to two or three servings. “That can be pretty significant for the [body] systems of a teen,” says McClain, the executive director of the Colorado School Counselor Association (CSCA).

School counselors in Colorado are finding that youth (mostly in middle or high school settings) have adopted more casual attitudes about marijuana since its legalization in the state, McClain notes. In recent years, he says, school counselors’ awareness and concerns have shifted from students smoking marijuana to their consumption of it via vaping or edibles, both of which feature a high concentration of tetrahydrocannabinol (THC), the component in marijuana that produces a high. These methods allow students to consume the substance in a more clandestine way than smoking does, including during the school day. Edibles such as candy or gummy bears also make exposure and consumption of marijuana more familiar and less foreboding to youth.

One way to counteract this issue is to train teachers and noncounseling school staff in mental health first aid, McClain says. This can better prepare school staff members to notice behavior changes and other indicators that a student might benefit from talking with a school counselor — about marijuana use or anything else, McClain says. CSCA also offers regular trainings and continuing education programming to its members on marijuana use and its effects in school settings, he adds.

“This just adds another layer of complexity to the job, one other thing that can be going on” with students, McClain says. “We [at CSCA] have made sure that we’ve provided [educational] opportunities by seeking out experts and people who are well-versed to provide information and training, and other states are in a similar situation. We may want to stick our heads in the sand, but at the same time, if we’re dealing with the day-to-day lives of our kids, we want to make sure we can provide help and support.”

Use as instructed?

Norton says that in his experience, only a small fraction of his clients who have medical marijuana cards use the substance for medical reasons. He believes the majority obtained a medical marijuana card so they could use it recreationally, which remains illegal in Florida, or because they have cannabis use disorder.

When asked, many of these clients are unable to tell Norton why they have a medical marijuana card, or they name conditions — such as headaches, attention-deficit/hyperactivity disorder and trouble sleeping — that aren’t listed on the state statute that allows for the use of medical marijuana. The only mental health diagnosis mentioned in Florida’s statute is PTSD, Norton says. However, there is language in the law that allows medical marijuana to be prescribed for “similar” conditions to those listed in the statute, which gives physicians flexibility. Norton says he has never heard of a client who has been turned down for a medical marijuana card.

“Even clients who perceive they are using it medically … judge its efficacy by [not only] if they feel better but also [if they] feel high or euphoric — and that’s not the point of medicine,” says Norton, the executive director of the National Board of Forensic Evaluators and an adjunct instructor at the University of South Florida’s rehabilitation and mental health counseling program. “People are using cannabis to feel better in the moment — sleep better, lessen anxiety, etc. — but at the expense of addressing their core problems, which are thoughts and behaviors. They’re missing the opportunity for recovery from their behaviors.”

Trogden agrees, saying, “The challenge, just as with any other medication, is that you really need therapy and counseling services to gain insights and awareness [about a presenting issue] along with taking the medication.” She adds that in her experience, medical marijuana has benefited clients who have depression or other mood disorders, trouble sleeping, anxiety, racing thoughts or a history of trauma. But Trogden also notes that in addition to its potential benefits, marijuana use can cause paranoia or lead individuals to use it as a “crutch” to cope with pain and other difficult feelings.

Britton has done research on medical marijuana and counseled clients who use it. She says the substance can be tied to symptom relief or otherwise benefit individuals who have chronic pain, sleeping difficulties, autism spectrum disorders, anxiety and hyperarousal, nausea (such as in those undergoing chemotherapy treatment for cancer) and a range of other issues. At the same time, she says that more research is needed.

In Britton’s experience, medical marijuana has helped some of her clients, while others did not reap any benefit — or even had negative outcomes — from its use. “And that’s consistent with the literature,” she notes. “Not everyone benefits. It’s not a miracle cure. But just like with antidepressants [and other psychotropic medications], it can soften a client’s symptoms … [so they can] do the therapeutic work. But they still need behavioral intervention.”

Now that marijuana is legal in most states, the counselors interviewed for this article agree that clinicians should include specific, detailed questions about its use during the client intake process. Asking clients how often and why they use marijuana can help practitioners better understand the context of their use and assess for dependence or cannabis use disorder.

Cannabis use disorder is characterized by behaviors that indicate that a person cannot stop using the substance even though it is causing the person social or health problems, such as overusing or craving marijuana or driving while impaired. According to the Centers for Disease Control and Prevention, individuals who use cannabis frequently or began using it in adolescence are at greater risk of developing this disorder.

Practitioners should embed questions into assessment about how much and how often clients use marijuana, similar to the way they would ask about clients’ consumption of alcohol, suggests Trogden, who teaches in an addiction counseling training program for the state of Louisiana and is the chief operating officer of a behavioral health organization in New Orleans.

“We should be assessing for a variety of things. It’s helpful to understand the whole person and get a holistic understanding of what’s going on. Substances would be a part of asking about medication, whether it’s blood pressure [medication], mental health medication or marijuana,” Trogden says. “It’s important to call it out specifically, [asking] ‘Do you use marijuana?’ If you just ask, ‘Do you use drugs?’ they’ll probably say ‘no.’”

Trogden says multiple clients have mentioned to her in later counseling sessions that they smoke marijuana after initially answering “no” to generalized substance use questions at assessment. As a result, she’s learned to ask specifically about marijuana in assessment because some clients do not consider it to be a drug or on the same level as illegal substances.

Britton suggests that counselors take a nonjudgmental, curious and respectful approach to marijuana assessment with clients. “If a client senses that you are going to judge them — on any topic — they’re probably not going to tell you,” she says. “Start thinking differently about how you ask [and] how you put it on intake forms. Get outside of judgment.”

When clients ask

Clinicians in states where marijuana is legalized may have clients ask whether it could help them with symptoms related to their presenting concern or mental illness. Counselors cannot prescribe medication, however, and making a recommendation or giving guidance on marijuana use — or any other kind of health regimen — goes beyond a counselor’s scope of practice, says Emily St. Amant, counseling resources and continuing education specialist for the American Counseling Association. She recommends that counselors refer to the 2014 ACA Code of Ethics, particularly Standard C.2.a.

St. Amant, a licensed professional counselor with a mental health services provider designation in Tennessee, urges counselors to respond to client questions about legalized marijuana use with a nonjudgmental attitude and a recommendation to speak with a licensed psychiatric medical provider about the topic.

“I would also provide education about why I’m making that recommendation: my own scope of practice [and how a prescriber is qualified] to discuss risks and benefits, side effects, drug interactions, etc.,” says St. Amant, whose background is in substance use counseling. “As a counselor, I need to ensure I’m staying within my scope of practice or what I’m personally licensed to do. We open ourselves up for liability and ethical violations when we drift out of our lane and into the lane of other areas of expertise. We also open ourselves up for potentially harming our clients if we impose our own values or ideas on them. That takes away their autonomy, can damage the therapeutic relationship and creates a power imbalance.”

Rather than offering advice to clients regarding legal marijuana use, counselors should focus on strengthening clients’ personal autonomy and decision-making skills, St. Amant emphasizes. Ultimately, it is the client, not the counselor, who must make and live with the decision to use (or not use) marijuana, medicinally or recreationally. 

“That doesn’t mean we leave them hanging and avoid helping in some way. That would be risking invalidating the client’s concern and a missed opportunity to be supportive,” St. Amant says. “We can help our clients by providing education, teaching problem-solving skills, eliciting their decision-making process, validating their concerns and promoting their empowerment and autonomy. … Even for us experienced counselors, it’s vital to ensure we are staying true to the fundamentals of client-centered principles. Those that are particularly relevant here include the fact that clients are the experts in their own lives and that we genuinely trust that they can decide what’s best for them.”

Decision-making

Talking about a client’s marijuana use in counseling sessions will have a very different dynamic depending on whether the individual is voluntarily pursuing treatment or has been mandated to complete therapy, often as the outcome of a court case.

In the second scenario, practitioners must remember — and explain to the client — that their work goes beyond the needs of the individual client, Norton says. The client may want to get their driver’s license returned after a DUI violation, for example, and this is contingent on completing a regimen of counseling sessions. 

“The counselor is responsible not only for the safety of their client but [also for] the safety of the public,” Norton says. “You have to address the issue [of their marijuana use]. You can’t ethically clear them if they’re just as unsafe now [at the conclusion of therapy] as when they first came to you. Counselors now have more than one stakeholder in what you do.”

Norton is a counselor supervisor, and his interns often work with clients who are mandated to complete counseling after a DUI or whose children have been removed from their care by child protective services because of their marijuana use and related behaviors. Norton also sees similar scenarios in the work he does as a substance use and DUI evaluator for the court system in Florida.

It is common for clients to try to skirt the sobriety requirements in mandated treatment situations by obtaining a medical marijuana card, according to Norton. This scenario puts the counselor in a no-win situation because the client has a way to legally obtain marijuana and continue their behaviors, he says. Addressing the root of the problem that brought the client into counseling becomes exponentially harder because the counselor is not a medical professional and cannot advise the client to stop a medically prescribed treatment, Norton points out.

Norton’s experience — and frustration — with this scenario led him to create a decision-making matrix (see below) for counselors to use when discussing marijuana use with clients who have been prescribed legal cannabis for medical use.

When addressing marijuana use in counseling sessions, Norton suggests that practitioners focus on clients’ motivation to change and their attitudes toward stopping their use of marijuana. His model offers different treatment scenarios for clients who have and have not been diagnosed with a substance use disorder and for situations in which the counselor has leverage (i.e., resources or outcomes the client wants, such as the return of a driver’s license or child custody, that are conditional to successful treatment completion).

In the case of clients who want to stop using cannabis, the counselor can collaborate with and refer them to a physician to find an alternative treatment. For those who do not want to stop using cannabis, the counselor can take a harm reduction approach to make gains toward behavior change in other ways, Norton explains. This includes strategies such as using motivational interviewing to explore the client’s thoughts on continuing their marijuana use or co-creating a “preventative strategy plan” with the client to identify benchmarks such as avoiding driving while using cannabis.

A harm reduction approach can prompt growth and behavior change in clients even while they continue to use cannabis — and much more so than simply leaving it unaddressed, Norton emphasizes.

Taking a nonconfrontational and supportive approach

Many of the harm reduction techniques Norton includes in his decision-making matrix involve collaboration between the counselor and the client. This ensures the counselor meets the client where they are, he says, and increases the likelihood of positive behavior change.

Katharine Sperandio, Daniel Gutierrez, Alex Hiller and Shuhui Fan, co-authors of the April 2021 Journal of Addictions & Offender Counseling article “The lived experiences of addiction counselors after marijuana legalization,” interviewed six professional counselors in Washington and Colorado (the first states to legalize marijuana for recreational use) who work with clients experiencing substance use disorders. They found that using a nonconfrontational, “motivational enhancement” approach with clients regarding marijuana use was more beneficial than addressing it head-on.

One participant in the study provided an example of a nonconfrontational approach. They broached clients’ marijuana use by framing it as a question: “Why do you think it’s a problem for you?” 

The co-authors also learned that with the legalization of marijuana, practitioners are seeing an increase in client justification and rationalization of marijuana use and less acceptance that it can be harmful or problematic, particularly among adolescents. Many clients were found to be using legal marijuana to numb negative thoughts and emotions, ease chronic pain, cope with trauma and “as a substitute for alcohol or other drugs rather than seeking [counseling] treatment because it was so readily available.”

The study participants also reported that clients were “more likely to walk out of treatment” and less likely to communicate about marijuana use (even if it was a source of other problems) if they felt there was a policy or recommendation to decrease marijuana use.

When school students are facing discipline for marijuana use, addressing it in a supportive way is the best approach to discourage those students from returning to risky behaviors, McClain says. When possible, it is helpful to involve the student and their parent(s) or guardian(s) as well as the school counselor and administrator to ensure that the student has a support system and reentry plan that doesn’t involve marijuana use and related behaviors, he says. Such a plan might include regular check-in conversations with a school counselor.

Taking a holistic approach, rather than only punishing, avoids setting the student up for failure and ensures that all of the student’s stakeholders are on the same page, McClain adds.

“We want to make sure they have a support system, including a counselor, to turn to for help. As much as we can surround them with support, hopefully the outcome will be better,” says McClain, who has worked as a school counselor for 17 years.

Case example

An adult woman came to see Britton for PTSD after experiencing sexual trauma. The client was experiencing intense flashbacks, having trouble sleeping and struggling with chronic pain. Britton surmised that the pain was related to her trauma because the client held her trauma in her body.

Britton used dialectical behavior therapy with the client, who made a small amount of progress in the first year but eventually stalled despite staying engaged in sessions and showing a willingness to try exercise and other actions that Britton suggested. The client continued to be plagued with sleep difficulties and night terrors, even while using a prescription sleep aid. Britton continued to co-treat the client while referring her to a practitioner who specialized in eye movement desensitization and reprocessing (EMDR) therapy.

“It took her a long time to forge trust; it took her several months to even tell me what happened. Once we got to that part, we started making some progress, but then she hit a wall,” Britton recalls. “Not only was the EMDR not helpful, but she [also] found it upsetting and she started going downhill, discouraged that she’d ‘never get better.’ … She felt really stuck and scared, and we weren’t making a whole lot of progress. The more she couldn’t sleep, the worse her symptoms got.”

Avgust Avgustus/Shutterstock.com

Eventually, the client brought up the possibility of trying medical marijuana. Britton responded by saying that she couldn’t advise her on whether it would be effective, but she could write a letter confirming that the client had PTSD in case she wanted to pursue obtaining a medical marijuana card.

Ultimately, the client did receive a medical marijuana card and began using cannabis to alleviate her pain and trauma symptoms. 

“It wasn’t a miracle cure. … She still presented with some trauma symptoms [while using medical marijuana], but it helped her sleep, and that was huge,” Britton says. “It didn’t ‘cure’ her, but it took the edge off so she could look at things a little clearer, and she started feeling some hope [after] feeling so deflated, so defeated. It gave her the energy to work toward some other behavioral treatments. 

“She wasn’t drug seeking; she was seeking symptom relief. It helped enable her to do the work that was in front of us [and] gave her the braveness to face it. It was just part of [her treatment]. It wasn’t the full answer, but I was glad we tried it.”

Bias management

The counselors interviewed for this article agree that clinicians have a responsibility to seek training, consult with colleagues and stay up to date on the regulations regarding marijuana in their area as well as the ways that its use — and misuse — can affect mental health.

At the same time, counselors are ethically bound to keep their personal views about marijuana (and all substance use) out of their counseling work, St. Amant notes.

“Substance use exists on a spectrum, and just because someone uses legal or illegal substances does not mean they have a substance use disorder,” she says. “Counselors must be careful not to impose their own values about substances use on their clients or project their own beliefs onto others. When the use of substances is conceptualized as a moral concern or a personal failing, we add to the stigma of substance use. Our attitudes must remain nonjudgmental and nonmoralistic when it comes to substances.”

 

****

Can counselors use legalized marijuana?

In states where marijuana use is legal for medicinal or recreational purposes, counselors have the right to use it on their own time, but they also have the ethical obligation to ensure that it does not cause an impairment to their clinical performance and their relationship with their clients. They can do this by approaching it the same way they do with alcohol use.

Counselors can ethically use legal substances as long as they do not perform clinical duties under the influence, the use does not impair their ability to function (e.g., seeing clients while experiencing a hangover or the prolonged impacts of the substance) and they are able to use the substances responsibly (e.g., not driving under the influence). If counselors choose to use legalized marijuana, one should be aware of how long the effects last (which can linger into the next day for marijuana) and ensure that no pictures are posted of them using the substance on social media.

If counselors have difficulty controlling their use or if it affects their health or clinical abilities, they should seek out an evaluation to see if they could benefit from treatment, and they should refrain from providing clinical care until it’s determined that they can do so safely and ethically.

Our ethics are founded upon ensuring client safety and preventing harm to those we serve, so our clients’ right to be protected from potential harm by their counselor using substances supersedes our personal freedom during the time in which we are working with them. Yes, we counselors are adults who are allowed to live our lives how we personally see fit, but, no, our personal choices cannot come at the cost of our clients’ safety.

See Standards C.2.g. and A.1.a. of the 2014 ACA Code of Ethics at counseling.org/ethics.

— Emily St. Amant, counseling resources and continuing education specialist for ACA

 

****

Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Women and alcohol: Drinking to cope

By Bethany Bray November 2, 2021

Holly Wilson, a licensed professional counselor (LPC) candidate in Colorado, knows firsthand that women can feel disconnected or overlooked in addiction recovery programs. When she decided to seek help for alcohol dependency through 12-step and other treatment programs, Wilson kept hearing staff in these facilities talk about addiction in terms of “hitting rock bottom” and “failure” and make blanket statements such as “all addicts are liars.”

These types of statements didn’t fit Wilson’s experience, but they did add to the self-criticism she was already feeling. A self-described “high-functioning drinker,” Wilson had always been able to hold down a job and had never been cited for drunken driving. She didn’t fit the messy, drunken stereotype that many people associate with those who need treatment for addiction.

“I kept drinking for a long time because I was able to show up and look good, but I was really dying inside,” says Wilson, a member of the American Counseling Association. “I just got sick of myself and saw that I wasn’t achieving what I could.”

Declaring in treatment that “failure” had brought her to this point didn’t feel accurate or helpful, Wilson recalls. “I had to subscribe to calling myself an alcoholic and [agree to] ‘your best thinking got you here.’ It reinforced a lot of the shame that I was already feeling about myself,” she says. “I was actively seeking help and wanted to get better, and the system I experienced felt like it was forcing me into this box that I was a rock-bottom failure. … I kept hearing the message that you have to hit rock bottom before you can get well, and I thought that was really dangerous.”

The focus that some treatment programs place on admitting failure or a sense of powerlessness over a substance can alienate or even drive away female clients because many women already carry intense feelings of shame about their alcohol use, Wilson notes. 

Despite Wilson’s difficult initial experience with treatment, she stuck with it and eventually found outpatient group therapy and individual therapy that felt welcoming and helped her learn more about the reasons why she drank. During her time in a women-only sober living house, she and her housemates were able to have deep and honest conversations about the trauma they had experienced — much more so than in the dialogue she’d experienced in coed groups, Wilson says.

Wilson’s recovery journey inspired her to help other women with similar experiences. After becoming a counselor and working in numerous positions in different substance use programs, she founded Women’s Recovery, an outpatient addiction treatment center for women with locations in Denver and Dillon, Colorado. Wilson serves as chief empowerment officer of the treatment center, which combines trauma-informed care with clinical treatment. The organization has a client-focused model that begins with asking clients what they want to get out of life, rather than prescribing what they should or have to do, Wilson says.

Treatment for alcoholism “doesn’t have to be through the lens of [a] power struggle over [a] substance,” Wilson says. “There is a misnomer that people have to get to rock bottom before getting help. … I would love to see a psychic shift [away from] that. It’s a problem whenever alcohol is getting in the way of things they want out of life. … The best thing we can do as counselors is shift our focus from that kind of rock-bottom-drunk perspective to an early intervention approach. We don’t have to wait until our clients lose everything and burn their life down to help.”

Multiple factors at play

Alcohol consumption and rates of alcohol use disorder among American women have been rising steadily in recent decades. Data compiled by the National Institute on Alcohol Abuse and Alcoholism indicates that although men consume more alcohol overall than women do, the gender gap is closing. In the nearly nine decades since Prohibition ended, the male-to-female ratio for measures of alcohol consumption — including prevalence and frequency, binge drinking and early onset drinking — has gradually narrowed from 3-to-1 to close to 1-to-1. 

Rates of alcohol-related hospitalizations and health concerns, such as liver problems and cardiovascular disease, are also increasing for women. In an article published last year in Alcohol Research: Current Reviews, researcher Aaron White noted that “although women tend to drink less than men, a risk-severity paradox occurs wherein women suffer greater harms than men at lower levels of alcohol exposure. … Because women reach higher blood alcohol levels than do men of comparable weight, their body tissues are exposed to more alcohol and acetaldehyde, a toxic metabolite of alcohol, with each drink.”

The stress of the COVID-19 pandemic, of which women are bearing the brunt with job loss and child care and caretaking pressures, is exacerbating these trends, says Todd Lewis, an LPC who authored chapters on alcohol addiction and prescription drug addiction in the ACA-published book Treatment Strategies for Substance and Process Addictions. Alcohol is often used as a fast-acting way to temporarily ease or ignore one’s emotions or psychological pain, notes Lewis, a professor of counselor education at North Dakota State University who also sees clients at a private practice one day per week. The immense stress that many women have faced throughout the pandemic, coupled with increased isolation and the extra strain on relationships, has played a role in furthering the rise in alcohol use among women, he says.

Although many factors are at play, Sarah Moore, an LPC with a private practice in Arlington, Virginia, points to the intersection of alcohol being readily used as a coping mechanism and alcohol being widely available and interwoven into social norms and expectations. The expectation to drink can also dovetail with the pressure to be thin and other issues related to body image that women face, including disordered eating, she adds.

It’s more challenging than counselors may realize, Moore says, for emerging adults to foster and maintain social relationships through activities that don’t involve alcohol. “For a lot of 20- and 30-somethings, that [drinking alcohol] is their entire social life. Older generations may not be aware of how hard it would be to skip out, how integral that is to social situations,” she notes. 

Moore, an ACA member, specializes in counseling for women, including issues related to alcohol dependency. She co-moderates a therapeutic group for women — Me, My Body and Alcohol — with Jyotika Vazirani, a psychiatric nurse practitioner and psychotherapist.

Alcohol is easily accessible and seemingly everywhere, Moore notes. It is often a part of sporting events and professional networking events, in which participation can be seen as a way to further one’s career, especially in high-pressure fields such as technology and law. The popularity of touring craft breweries and wineries also continues to grow. In many areas, alcohol can be purchased via delivery or curbside pickup at grocery or liquor stores.

One ironic aspect of American culture is that it frowns on both alcoholism and sobriety, Moore and Lewis note. “If you lose weight or quit smoking, everyone wants to know your secret,” Moore says, “but if you say you’re not drinking, they don’t know how to respond” in social settings. 

And if individuals choose not to drink in social situations, they can face stigmatizing comments such as “you’re not having any fun,” Lewis adds.

In counseling, Moore role-plays and talks through scenarios with clients who have anxiety about declining alcohol at work events and in social situations because drinking has become so ingrained in these settings. She works with clients to plan and practice ways to artfully dodge questions and comments about their beverage choice.

Intertwined with trauma

All of the counselors interviewed for this article note that women who have an unhealthy relationship with alcohol often have experienced trauma in their past, are currently experiencing trauma or, in some cases, both. It is imperative that counselors are sensitive to this potential connection; use trauma-informed methods; are able to screen for posttraumatic stress disorder, intimate partner violence and abuse (physical, emotional, sexual, etc.); and know when and how to refer clients for specialized care when appropriate.

Sophie Hipke, an LPC in training at Women’s Recovery Journey, a women’s-only outpatient recovery program within the counseling clinic at Family Services of Northeast Wisconsin, says a vast majority of clients there have experienced (or are experiencing) “significant” trauma and turned to alcohol to cover up or numb painful emotions. Clients are often aware that alcohol won’t fix their problems, but they feel that it holds the promise of offering temporary relief, notes Hipke, who is training to be fully certified as a substance abuse counselor.

Many of the clients that Hipke and the counselors at Women’s Recovery Journey treat started drinking alcohol at an early age, sometimes as young as 11 or 12. For these clients, alcohol was often a way to escape an abusive household or deal with a loss or trauma, Hipke says.

“Substance use is often just a symptom, and the client has been self-medicating [to cope with] trauma or mental illness or both,” Wilson says. “We find that the majority of people who are seeking substance use disorder counseling have a reported history of trauma. There’s been a shift [among mental health practitioners] in the recent decade to recognize that it’s intertwined. … In order to really help people recover, we have to help them dig out of that trauma that has built up over time.”

For Wilson, the trauma of her brother’s death was what “pushed her over the edge” with her drinking, she says.

Clients who have a substance use disorder and a trauma history need a two-pronged approach in counseling, Wilson notes. They need to process and heal from past trauma and develop skills that allow them to deal with new traumas as they (inevitably) happen. “With both ‘big T’ trauma and ‘little t’ trauma, every person has a threshold and level of internal resiliency, and they can only take so much,” Wilson says. “If they don’t have the ability to cope as new trauma comes in, they are overwhelmed. [That’s when] we find ourselves continuing to turn to that substance over and over.”

Building rapport with clients is always an important aspect of counseling, but that is especially true with this population, Moore says. Women often feel intense amounts of pain and shame related to their trauma and alcohol dependency or addiction, so it’s vital that counselors focus on fostering a nonjudgmental and trusting relationship with these clients before delving into the hard stuff. Practitioners should also be patient, understanding that it may take these clients a long time before they feel stable enough to process their trauma, Moore advises. 

Because trauma commonly dovetails with alcoholism and problem drinking in women, counselors should carefully choose treatment methods that are appropriate for this population, Moore stresses. Supports that are commonly used with male clients may not be helpful for female clients, especially if they have experienced sexual abuse or domestic violence.

Moore and the other counselors interviewed emphasize that recovery treatments that involve mixed-gender groups may not be appropriate — and could even be harmful — for female clients who have a substance use disorder. The vulnerability involved in talking about deeply personal issues that tie into their alcohol use can be triggering in coed settings for this client population, especially if they have experienced past trauma involving a man.

Counselors should thoroughly vet their local Alcoholics Anonymous (AA) chapter and other coed support groups before recommending them to female clients, Moore cautions, because these groups could exacerbate clients’ feelings of shame and possibly even retraumatize them. “AA can feel disempowering to women clients,” she says. “A lot of these women have a history of sexual trauma, and being around men is not therapeutic [for them] necessarily.” On the other hand, female-only group counseling or support groups can be powerful settings for female clients to feel supported and understood.

Lewis notes that although mutual aid groups such as AA can be a helpful supplement to counseling for some clients, practitioners should be mindful that AA’s 12-step method has a Western, patriarchal and masculine bias. The organization’s founding roots also have ties to Christianity, which can further alienate some clients, he adds.

Women for Sobriety (womenforsobriety.org) can be a helpful alternative, Lewis says. The organization’s model is based on a series of steps, like AA, but with an empowering focus, he explains.

Lifting the shame

Feelings of shame are common with women who have an unhealthy relationship with alcohol. Because of this, these clients often harbor denial or strong urges to hide their problem even from their therapist, which can affect the dynamic in counseling sessions, Moore notes. It can also cause these clients to cancel sessions or stop counseling altogether.

Moore urges counselors to be prepared for — and patient with — the resistant behaviors that this population may exhibit. “This is a challenging population to treat,” Moore acknowledges. “It [alcohol use] is something that can be a very closely guarded part of their life.” 

Resistance and secrecy can be especially prevalent among female clients who are successful in their careers or who work in helping professions such as medicine or counseling, Moore says. Throughout her career in the mental health field, she says, she has witnessed many peers “quietly struggle” with alcohol misuse.

Women are often socialized to be concerned with how others might judge them, which can cause perfectionist tendencies and feelings of shame, Wilson points out. “One of the things that keeps women from getting help is that they can show up, put their best foot forward and play the part of someone who is well when they’re suffering inside. That can be really hard to break through as a counselor,” Wilson says. “Women also have an incredibly high pain threshold. We can take a lot before we break down.”

Hipke finds that women’s shame around drinking often dovetails with parenting issues and feelings of failure as a mother. Many of the clients in the recovery program where Hipke works have had child protective services involved with their family or children removed from the home because of alcohol- or substance-related offenses. These women often feel ashamed for being a burden to family or others who care for their children when they are unable to. The feeling of being a bad mother “really cuts deep for them,” Hipke says.

“Society’s expectation is that women are supposed to naturally be a good mother,” Hipke points out. “Society sees them as doing this [being addicted to alcohol] to their kids rather than doing it to themselves.”

Clients always need an atmosphere of nonjudgment in counseling, but that need is magnified exponentially for this client population because of the associated shame, Hipke says. Practitioners should be hyperaware of the language they use with these clients to ensure they are not reinforcing feelings of shame, she stresses. Counselors must also be careful not to frame a client’s situation as something that they brought on themselves. Statements that assign blame, such as “you’re choosing alcohol over your children,” are not only hurtful for these clients, Hipke says, but also carry the false message that substance use disorder is a choice.

“Be aware of how you’re talking about addiction [and] reiterate that addiction is not a choice,” Hipke urges. “We don’t see any other mental illness as a choice, but people often see addiction that way.”

Part of fostering a welcoming and nonjudgmental atmosphere in counseling is being sensitive to the needs and stressors that women might be juggling outside of counseling, such as child care or transportation. This might call for clinicians to exercise greater flexibility by offering to use telebehavioral health with these clients or allowing them to bring an infant or small child into counseling sessions when child care is unavailable.

Wilson’s facility offers group counseling both in the mornings and the evenings to accommodate clients’ schedules. “We [counselors] need to accommodate women who have a lot of balls in the air already,” she says. “There can be a lot of pressure for women to be the anchor of their family, the scheduler, and that can be something we need to be cognizant of.”

Practitioners may also need to think of creative ways to broach the subject of alcohol use with female clients in counseling sessions without being too direct or aggressive. Otherwise, these clients may stop attending. One method Moore likes is asking clients detailed questions about their sleep habits, including whether they use alcohol as a sleep aid.

“Find ways to get the conversation started early. Don’t wait for it to come up,” Moore says. “It can be hard to get an authentic answer from women regarding alcohol because of the [associated] shame. Sleep can be a good way to ask and bring it up because alcohol use can really mess up sleep.”

Lewis also urges counselors to weave assessment questions regarding alcohol use into conversation with clients rather than firing one question after another at them. This approach intersperses questions about what is happening in the client’s life beyond drinking, such as in their home and family life and relationships, he says.

Instead of asking direct questions about the quantity and frequency of their alcohol consumption, using prompts such as “What does a typical week look like for you in terms of drinking?” can offer a gentler way to query clients about their alcohol use, Lewis says. 

For his doctoral dissertation, Lewis researched binge drinking among college students through the lens of Adlerian theory. He found that unhealthy relationships, including problems forming and maintaining relationships, were more often a predictor of women’s drinking behaviors than of men’s. As he points out, dependence on alcohol can cultivate an unhealthy cycle: Poor or absent relationships can contribute to alcohol use, which in turn can hinder an individual’s ability to maintain or build new relationships. So, asking female clients about their relationships and social supports can help counselors understand when further questioning about alcohol use might be needed, Lewis says.

(See the Counseling Today article “Becoming shameless” for an in-depth look at helping clients with feelings of shame.)

Tailoring treatment

Equipping clients with coping mechanisms, including ways to quell critical self-talk, is another important part of working with this population. Clients will need robust, healthy coping skills as they work to eliminate alcohol consumption — the quick, accessible coping tool they have come to rely on. 

Vicky Gosselin/Shutterstock.com

Providing psychoeducation that addiction is a disease and that recovery involves rewiring one’s neural pathways for decision-making is helpful, Wilson says. Her initial work with clients includes a focus on coping mechanisms that will help them regulate their emotions. She also works to build up clients’ communication and social skills, which may be underdeveloped because of the individual’s history of trauma, mental illness and substance use.

“The only thing they’ve known to use to cope is the substance, so we need to replace that right away,” Wilson says. “We [the staff at Women’s Recovery] are big believers in skill building. We start with loading clients up with all sorts of coping and grounding skills [as well as] the message that this is going to be a lifelong journey. Clients are recovering, and it will take constant work.”

One nice thing about outpatient treatment is that clients learn to live without substance use in everyday life during treatment, Wilson notes. Clients can see what triggers come up and learn how to address them as they navigate work, family life and relationships while living at home.

Hipke notes that group counseling can also be a rich setting for female clients to learn coping mechanisms, both because they are exposed to the lessons that other women have learned during their recovery journeys and because they are provided with a safe place to strengthen their social and relationship skills.

“Group [counseling] is the most powerful part of our program. It resonates with them to hear others’ stories, helps them build bonds and also holds them accountable,” Hipke says. “It’s powerful [for clients] to know they can share stories and talk about whatever they need to, and it won’t leave the room. As a therapist, we can point things out to them all day long, but it’s so much more powerful to hear it from a peer.” Hipke has noticed that she can say something repeatedly to a client in an individual session, but it often won’t “click” until the client hears the same message in the group.

Lewis and Hipke note that in individual counseling, motivational interviewing is a useful method for building rapport and helping clients who may be resistant or ambivalent to behavioral change. This approach can also be beneficial when counseling female clients who are in denial or who have complicated feelings that are exacerbated by the stigma and shame associated with their alcohol use. 

The counselors interviewed for this article also mentioned cognitive behavior therapy (CBT), Gestalt techniques and trauma-informed modalities, including eye movement desensitization and reprocessing, as being particularly helpful with this client population. Hipke says that using a strengths-based approach can also be useful, as can including a client’s partner or family in sessions, when appropriate.

Including clients’ family members or others in counseling sessions can help clear up misunderstandings and hurtful feelings that linger regarding a client’s addiction and past behavior, Hipke explains. In these cases, a counselor can act as moderator to support and guide conversations toward healing. “Having kids, parents or siblings join in on sessions for the therapist and client to be able to talk more about addiction and provide a safe and neutral space to have discussions can be very healing for both the client and their family,” she says.

These clients may also need to spend significant time working on self-talk and intrusive thoughts and learning how to deal with difficult feelings in a healthy way. With self-talk, part of the work involves helping female clients hold themselves accountable while resisting the urge to be overly critical and beat themselves up, Hipke says. Mindfulness and CBT can be particularly helpful in these areas, she adds.

Many clients, especially those with abuse histories, must unlearn behaviors they adopted over time to block out powerful emotions such as anger, sadness and happiness, Hipke says. These women often struggle to find the words to explain what they are feeling. Hipke uses an emotion wheel to help clients name their emotion, recognize how it manifests in their body and identify why it’s a difficult feeling for them to experience.

“For many clients, they were either punished or wouldn’t get their needs met if they showed emotion. … They often need to rediscover sadness or anger and realize that it’s OK to feel those emotions, or even that it’s OK to be happy. They often don’t know what to do with being happy,” Hipke says. “From there, we identify why it’s so difficult. What has led to the place where feeling sad or angry isn’t OK? And then we begin to dismantle that. Just labeling it, identifying it, is helpful — and then they can match coping skills to the emotion they are feeling.”

Preparing for relapse

When doing counseling work with women who are addicted to or dependent on alcohol, it is important to be prepared for the possibility of relapse. 

It can be helpful to talk frequently about relapse prevention skills, both in group and individual counseling, Hipke says. This includes being able to recognize the signs that an individual might be headed toward relapse. She also listens for instances when clients mention going through a stressor. This presents an opportunity to offer extra support and check on how the client is coping, including asking gentle questions about the possibility of the client feeling an urge to return to substance use.

Once again, it is important for counselors to provide nonjudgmental responses, Hipke stresses. If a client relapses, counselors should normalize the experience and celebrate that the client recognized it and shared it with the therapist, she says. Women are often afraid to tell their counselor about a relapse. So, when they do, Hipke recommends that clinicians assure them that it’s not a sign of “failure,” either on the part of the client or the counselor.

Hipke also emphasizes that counselors should not take client relapses personally. “For a lot of the women [in our program], they struggle with balance in different areas of their lives. They’re not just stopping drinking, they’re making a lot of behavioral changes in their lives,” Hipke explains.

She often talks with clients about how it’s normal for relapses to occur during any kind of behavioral change. “It’s not the relapse that we want to focus on but what to do after,” Hipke says. “What can we do differently to make sure it doesn’t continue happening, [and how can we] keep [clients] from beating themselves up, because that can lead to more relapses.”

 

****

How much is too much?

Counselors shouldn’t take a one-size-fits-all approach to assessment questions about a client’s alcohol use because women form dependency on alcohol for different reasons — and in different ways — than men. Practitioners should focus more on the context and reasons why a female client drinks alcohol rather than on the quantity, says Holly Wilson, the founder and chief empowerment officer of Women’s Recovery, an outpatient substance abuse treatment program for women in Denver.

Questions about the number of drinks a client consumes also have the potential to spark countertransference issues, notes Wilson, a licensed professional counselor candidate. Counselors will have personal feelings about how many drinks are acceptable, and they must be careful not to project those assumptions onto clients.

“It doesn’t matter if you would have a problem doing what they’re doing … or [if] the quantity or frequency of the client’s drinking may be something you’re fine with, but they’re not,” Wilson says. “It doesn’t have to be according to your own personal standards of drinking or substance use.”

Instead, she advises counselors to focus on exploring the client’s relationship with alcohol. The CAGE questionnaire can be a helpful tool to use with female clients, Wilson says, because it focuses on how a person feels about their drinking. CAGE poses four questions that can prompt further dialogue with the client:

  • Have you ever felt you needed to Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt Guilty about drinking?
  • Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

 

****

Recommended titles

Here are some books that Sarah Moore uses with individual and group clients:

  • “Can I Keep Drinking?: How You Can Decide When Enough is Enough” by Cyndi Turner
  • “Between Breaths: A Memoir of Panic and Addiction” by Elizabeth Vargas
  • “The Sober Diaries: How one woman stopped drinking and started living” by Claire Pooley
  • “This Naked Mind: Control Alcohol, Find Freedom, Discover Happiness & Change Your Life” by Annie Grace
  • “Quit Like a Woman: The Radical Choice to Not Drink in a Culture Obsessed with Alcohol” by Elizabeth Whitaker

 

 

****

Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The intersection of childhood trauma and addiction

By Shannon Karl April 13, 2021

Substance dependence leads to persistent negative consequences and the loss of human potential. These consequences often include chronic health problems, dysfunctional family environments, harmful economic impacts and premature death. According to the Centers for Disease Control and Prevention (CDC), 21.2 million individuals in the United States met the criteria for a substance-related disorder in 2018. Deaths from overdose have tripled in less than two decades, with over 70,000 annual drug overdose deaths in 2019, 70% of which resulted from opioids such as morphine and fentanyl.

Substance-related disorders include 10 classes of drugs: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; hypnotics, sedatives and anxiolytics; stimulants; tobacco; and other/unknown substances. Exposure to childhood trauma increases one’s risk of addiction across classifications, along with deleterious factors such as physical health and socioeconomic challenges. The Adverse Childhood Experiences (ACE) study, originally conducted by Kaiser Permanente and the CDC from 1995-1997, identified categories of trauma that can occur prior to age 18. These include physical abuse and neglect, emotional abuse and neglect, sexual abuse, and household dysfunction — e.g., mother treated violently, household substance misuse, parental incarceration, parental mental illness, and divorce.

These factors make up the 10 components of the ACEs score, with research supporting higher likelihood of substance-related disorders as exposure to ACEs increases. According to the American Society of Addiction Medicine (ASAM), addiction has biological, psychological, social and spiritual manifestations. Given the deleterious nature of addictive etiology, professional counselors need to be aware of the vulnerability to addiction for those affected by childhood trauma. The intersection of ACEs and addiction holds pervasive negative impact across the life span.

The National Institutes of Health (NIH) asserts that traumatic events can serve as triggers for substance misuse. NIH reported that 38% of high school seniors admitted using an illicit substance in 2019, with marijuana being the most frequent substance utilized. Startlingly, 11.8% of eighth graders reported marijuana use. In addition, 11.7% of high school seniors reported daily nicotine use, and more than half acknowledged using alcohol in the prior year.

Exposure to ACEs can lead to toxic stress and myriad negative consequences, often including lifelong deleterious effects on physical and mental health. The high rates of individuals living with the trauma of ACEs is startling — 61% of individuals have endured at least one ACE, and nearly 25% of individuals report three or more ACEs. There appears to be specific vulnerability to addiction for those who have experienced four or more ACEs. The higher the ACEs score, the greater the negative health impact. More than half of adolescents who live with mental health concerns also have diagnosable substance-related disorders, which underscores the comorbidity of the issue.

Ramifications of ACEs can include addiction, reduced access to education, and vulnerability to sexual exploitation and trafficking. Tobacco and prescription drug use is higher among those with ACEs, and illicit drug use increases more than twofold with each positive ACEs category. Other lifelong instability factors that have been shown to correlate with ACEs are high-risk sexual behaviors, early pregnancy, suicide attempts, sleep disturbance, poor dental health and multiple physical health concerns. Both children and adults with extant mental health issues misuse substances at higher rates.

According to the U.S. Surgeon General, approximately 10% of children live with mental health concerns that rise to a clinical level, with major depressive disorder representing a leading cause of disability in children worldwide. Research supports the strong connection between experiencing adversity during childhood and the ensuing development of addiction. More than two-thirds of children will experience a traumatic event before the age of 16. And with the current pandemic, many children are in homes that are violent or otherwise unsafe. Alarmingly, domestic violence incidents were up 30% in 2020, exposing untold youth to at least one of the ACEs factors.

Treatment needs

Reports regarding heightened clinical levels of anxiety and depression among the general population suggest that stress related to the COVID-19 pandemic affects everyone. Adolescence already represents a critical developmental period for initial onset of mental health and substance-related disorders, so the vulnerability for this demographic is further increased. ACEs are a clear and extant risk factor, with survivors of childhood trauma 15 times more likely to attempt suicide, four times more likely to develop an alcohol-related disorder, and 2.5 times more likely to smoke cigarettes. For survivors of childhood trauma, physical and emotional issues often manifest in adolescence and follow into adulthood.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 21.6 million people ages 12 and older needed treatment for substance use in the U.S. in 2019, whereas only approximately 2.6 million people (or slightly more than 12%) received it. These are glaring treatment needs that crosscut demographics. Fentanyl, which can be lethal, is sold in multiple forms on the “street,” continuing the opioid crisis in our country. Tens of thousands of overdose deaths occur per year, with close to 11 million individuals disclosing inappropriate opioid use. Those with ACEs scores higher than 6 were over 1,000 times more likely to use injection drugs.

Chronic substance abuse, a clear risk factor for those exposed to trauma, leads to premature death in alarmingly high numbers. Adolescents with experience of major depressive episodes are more likely to use substances across categories. Coincidingly, 60% of U.S. youth with depression do not receive mental health treatment. Addressing the physical and mental health impact of substance use alone is estimated to cost Americans more than half a trillion dollars annually. The CDC has developed a resource that highlights the available research support for evidence-based prevention of ACEs at cdc.gov/violenceprevention/pdf/preventingACES.pdf. These strategies focus on systemic community-based information and training. Emphasis is also placed on physical health, positive behaviors and supportive environments.

Treatment considerations

Certain populations have increased vulnerability to substance-related disorders due to environmental and genetic factors. This stems from the neurobiological underpinnings of the addictive etiology to the effects of toxic stress. Individuals born into households in which they are exposed to ACEs are more vulnerable to addiction, including process addictions centered on gambling, internet gaming, sex, shopping, work, social media and so on. The use of trauma-informed interventions as early as possible can mitigate deleterious effects and provide protective measures against substance-related and other mental and physical health issues. The CDC offers trainings for those interested in learning more about the prevention of ACES (see vetoviolence.cdc.gov/apps/aces-training/#/#top).

All clients should be evaluated for trauma and addiction history. The concurrence of mental health concerns and substance abuse necessitates treatment that addresses these challenges. Trauma increases the already high comorbidity (upward of 50%) between mental health and substance use diagnoses. Prevention and early intervention services can examine frequency, severity and duration of both the trauma experience and the addiction. The conceptualization of substance use disorders occurring on a continuum (as detailed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) underscores the importance of prevention and early intervention.

According to the CDC, research shows a propensity to self-medicate with substances to escape or numb negative thoughts and feelings. This suggests that escape from emotional pain triggers the onset of addiction. Women, adolescents and individuals from marginalized populations are most vulnerable to these effects, although anyone can experience childhood trauma and struggle with ensuing addiction.

Clinicians should develop individualized treatment plans and strong referral systems. Genetic and environmental factors work in combination. Thus, we need to gain understanding of these interactive effects. Long-term supports and provision of physical and dental health services can be important for individuals exposed to ACES, especially considering the likelihood of comorbidity with a physical health diagnosis. Increased rates of unemployment and job dissatisfaction represent additional treatment needs.

Relational challenges

Difficulty forming healthy relationships across the life span is a hallmark of surviving childhood adversity. Counseling professionals should thus incorporate strategies for strengthening the family and community. Holistic and family counseling services are beneficial. This includes the provision of psychoeducation and parenting education to address overall life skills, mindfulness and grounding techniques, positive coping strategies and career counseling services. Trauma-focused cognitive behavior therapy (TF-CBT) and multisystemic therapy have shown both short- and long-term benefit with these clients. This can be combined with addiction treatments such as medication-assisted therapy for alcohol or opioid use disorders. The combination of psychoeducation and supportive, trauma-informed and empirically based substance misuse treatments can span the broad needs of this population. All treatment modalities and providers should integrate trauma-informed care.

Early identification and intervention remain important to minimize risks and break deleterious family patterns. Removal of barriers to treatment includes addressing stigma and increasing education for families and communities. Larger scale prevention programs, inclusive of early intervention and postvention services, are indicated. The development of individualized treatment strategies that incorporate trauma-informed interventions are also vital.

Professional counselors are charged to advocate for clients and communities. Screenings in hospitals, clinics and public health facilities can help identify those at risk for substance misuse, especially those with trauma histories, and link them with treatment services. Psychoeducation in schools and community agencies also can improve outreach and access to care. Parenting education classes and life skills trainings are other examples of additive ancillary services. Incarcerated populations are particularly affected, with some studies suggesting a trauma history for nearly the entire population of female inmates. Professional counselors working across these settings should be aware of risk factors and assessment protocols that are culturally competent and inclusive of multiple demographics.

Effective treatments for individuals affected by trauma and addiction can include eye movement desensitization and reprocessing, motivational enhancement therapy, TF-CBT, dialectical behavior therapy, assertive community treatment and family behavior therapy. Psychotropic medication and psychiatric care may be indicated to fully address these complex issues. Some medications may benefit multiple issues (e.g., bupropion for both depression and nicotine dependence). Case management and occupational assistance represent important ancillary services for many clients. Community vouchers can be given for transportation and health care access and allow for possible employment opportunities.

Although thorough and comprehensive treatment can be expensive, it pales in comparison to the economic costs associated with addiction and premature death. With annual estimates for addiction and premature death as high as $740 billion, there is a need for legislation that funds prevention and early intervention services for those affected by trauma exposure and addiction. Given appropriate access to treatment and support, many individuals living with the effects of childhood trauma and addiction can make positive and lasting improvements. The cycle of intergenerational trauma transmission can be broken, providing positive ripple effects for future generations. Individuals can thrive and build healthy families despite their adverse experiences.

Community impact and integrated care

A multitiered approach to looking at immediate issues such as addiction is imperative for individuals exposed to ACEs. Addressing the trauma and providing familial services, social support and preventive measures remains imperative. All professional counselors can emphasize trauma-informed and integrative care. Here are a few simple strategies to tackle this complex issue: Listen with empathy, garner training in trauma-informed practices, develop a strong support and referral system, and provide specialty services to treat the trauma and the addiction. Working together, mental health professionals across disciplines can help survivors of childhood trauma manage life in healthy and productive ways.

The global health pandemic has increased utilization of distance-based services such as telemental health counseling. This modality can provide easier access to services for individuals in rural communities, those with transportation challenges and those with other impediments to treatment.

It remains important to highlight the team approach in addressing the complex issues of childhood trauma, addiction, and the ensuing physical and mental health sequelae. The pervasive nature of this challenge engenders a call to action. Data collection through thorough assessment can inform community decision-making and provide program funding. The Youth Risk Behavior Surveillance System assesses crosscutting data that are available at the local, state and national levels. The National Survey of Children’s Health and the National Crime Victimization Survey also collect data that can inform service provision.

The CDC provides information to promote safe childhood environments and mitigate ACEs exposure and subsequent addiction and disease. On a micro level, professional counselors can focus on parenting and family skills, mentoring, social emotional learning, job skills, and psychoeducation regarding healthy family and interpersonal relationships. On a macro level, professional counselors can promote community connection, mentoring relationships and positive social norms. The critical importance of trauma-informed interventions that are tailored to individual or family circumstances, along with communitywide prevention strategies, are necessary for addressing these serious and prevalent risk factors. These programs can assist children, parents and families beyond mitigation of symptoms.

Family-centered treatments for addiction can address the intergenerational impact. The deficits that come with trauma and addiction are offset by evidence-based interventions and prevention strategies. Access to programs should be available for all levels of care and can be implemented concurrently with ancillary services. Counseling settings can include the home, school or office, and often will involve multiple integrated health care professionals. Given the complexity of the challenge, comprehensive treatment services that include bridging home and school environments and the larger family system remain imperative. The widespread impact of ACEs and their intersection with addiction calls for coordinated care across disciplines. This includes effective tracking and coordination of prevention and intervention services across all aspects of service delivery.

Intergenerational patterns of trauma transmission represent a vicious cycle that professional counselors can help break. Prevention programs must address household dysfunction and adversity, especially considering that ACEs indicate earlier onset of substance consumption. The idea of numbing or comfort-seeking suggests that childhood adversity can lead to addiction through attempts to relieve distress. Quality mental health care can address and ameliorate these maladaptive coping mechanisms. ACEs are also correlated with substance use disorder in older adulthood, underscoring the lifelong ramifications of exposure to childhood trauma.

Addiction treatment facilities partnering with comprehensive and wraparound services can provide targeted interventions to address individual trauma experiences. Tackling the systemic nature of childhood adversity through family services and community advocacy provides additional resources for clients. Professional counselors are an integral part of the overall treatment team. Clients can and do learn new patterns of behavior and positive coping mechanisms that help them live longer, healthier lives. The benefits of prevention and early intervention should not be undervalued. Treatment is ameliorative for trauma and addiction and often engenders positive change in individuals and families.

Professional counselors can assist community members in locating resources and addiction treatment centers across the country via SAMHSA’s national helpline: 800-662-HELP (4357). Viewing survivors of childhood trauma who struggle with addiction or other maladaptive coping mechanisms from a strength-based approach is imperative. These struggles are not born of characterological weakness but result from the impact of lived trauma experiences. Empathy and care go a long way in successful work with trauma survivors.

Conclusion

Abuse, neglect and household dysfunction clearly lead to physical and mental health challenges. The risk of addiction, early death and intergenerational trauma transmission increases with each adverse childhood exposure. Use of alcohol and other illicit substances damages mental and physical health in numerous ways and often intersects with the trauma experience. Vulnerable children and adolescents can and must be protected. Professional counselors play pivotal roles now more than ever.

In 2020, SAMHSA reported a 900% increase in call volume to its disaster distress helpline (800-985-5990). Nearly half of Kaiser Family Foundation respondents asserted that the COVID-19 pandemic is detrimental to their overall mental health. The global health pandemic underscores the burgeoning treatment needs for increasing numbers of vulnerable people. Experiencing trauma in childhood can hinder the individual in all aspects of life. The negative reverberations for families and communities should make this everyone’s issue. Professional counselors hold the potential to help effect positive change for innumerable individuals, families and communities. Let’s make an impact — now and into the future.

 

****

Shannon Karl is a professor with the Department of Counseling at Nova Southeastern University, a licensed mental health counselor (supervisor) in Florida, an active member of the American Counseling Association, and a past president of the Association for Spiritual, Ethical and Religious Values in Counseling. Contact her at shannon.karl@nova.edu or linkedin.com/in/shannon-karl-phd.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

DXM: A drug in plain sight

By Emily Weaver, Sharon J. Davis and David Saarnio November 10, 2020

We are writing this article to raise awareness among parents and counselors about a legal and easily accessible drug that is widely used by adolescents to get high: dextromethorphan (DXM). DXM is an ingredient found in certain medications meant to help us get better, so teens frequently abuse this drug without being aware of the potential consequences and dangers. Given the personal insights and experiences we have with the damaging effects of DXM, we are sharing this story in hopes of reaching a larger population and creating more efficient prevention strategies related to teen drug use.

****

When co-author Sharon Davis’ son was 17, he began abusing over-the-counter (OTC) cough medicine. He had been using marijuana and K2 (synthetic marijuana) for a few years, but it was Coricidin — a cold medicine marketed as being for people with high blood pressure — that really damaged him.

Sharon’s son became a different person. He had always been a moody kid, but his moodiness turned to anger, mania and psychosis. Over a four-month period, his father and mother took him to the emergency room four times. It wasn’t until he attempted suicide that they really got him the help he needed and found out the full extent of his addiction.

He had been introduced to Coricidin through some friends. Soon he was using 30 pills at a time. Coricidin use led to cocaine use. Cocaine use led to methamphetamine use. Two years later, he is working on recovery, but his mind and mental health will never be the same.

According to the Partnership for Drug-Free Kids, 50% of American teenagers have misused a drug, and drug overdose is the fourth-leading cause of death among teens. Parents, counselors and other adults are well aware of the problem of teen drug use, and the nation’s opioid epidemic has brought the topic of medication misuse to the forefront of public attention. That attention is long overdue. However, that focus also misleads us because other critical concerns are being overlooked.

For example, our society is largely neglecting to talk about the large-scale problem of adolescent misuse of OTC medicine and its potential as a gateway to other drugs. In fact, OTC cough and cold medicine is one of the most popular drugs that youth use to get high. According to the Monitoring the Future survey funded by the National Institute on Drug Abuse, more teens got high from OTC medicine in 2019 than from prescription opioids.

Why OTC?

OTC cough medication is easy for teens to get. In some places, teens can purchase these medications from their local convenience stores. Furthermore, most stores have these medications out on the shelf where they are easy to steal. Teens can also get them from peers and even from parents. Because they don’t necessarily perceive these types of medications as “dangerous,” many parents will store them in an unlocked medicine cabinet, unknowingly allowing their teens easy access to them.

The psychoactive drug in OTC cough and cold medicine is DXM, which falls into a class of drugs known as dissociative hallucinogens. Other drugs in this category include PCP, ketamine and nitrous oxide. The Food and Drug Administration (FDA) approved DXM as a cough suppressant in 1958. It remains legal to buy and use in the U.S. DXM is a safe drug when used as directed, but when used in 10 times or more the recommended dose, it acts as a powerful dissociative, distorting reality. Currently, 85%-90% of OTC cough medications contain this effective antitussive (cough inhibitor). DXM is a synthetic opioid drug, but it activates different opioid receptors in the brain than prescription opioids do.

Teens typically misuse DXM to feel the euphoric, dreamlike experiences and hallucinations it causes. When individuals use DXM to get high, they experience various levels of inebriation, known as plateaus.

There are four plateaus associated with DXM. The first plateau involves mild intoxication and stimulant-like effects. The second plateau features increased intoxication and mild hallucinations. At the third plateau, the user enters a state of altered consciousness with impaired senses and psychosis. The fourth plateau involves a sense of derealization (in which the world appears unreal) and depersonalization (e.g., detachment from the self).

Users describe the higher plateaus as akin to being in other realms or alternate universes. Commonly, users feel an out-of-body sensation, like being transported to another dimension. They lose their sense of self and time. It is common for users to post videos or blogs about their experiences, including what they felt like and what they saw while high. The slang term robo-tripping is how many teens refer to being high on DXM. Slang terms for the drug itself include triple-C’s, robo, skittles, red hots and dex.

Why is DXM problematic?

DXM is a dangerous drug when used outside of therapeutic doses, yet little has been done to curb its misuse among teens. For decades, we have known about the consequences of misusing this drug, including seizures, hyperthermia, tachycardia, psychosis, mania and even death.

The opioid epidemic in this country is a national crisis. It is worthy of public attention and government funding to address. At the same time, DXM misuse among teens is also startling, and yet it is rarely highlighted. This drug is more popular than opioids among young people, and it is legal, inexpensive and easy to get.

It is imperative that prevention efforts and policies address this problem. For example, laws similar to those passed in 2005 that required pharmacies to move the popular methamphetamine-making drug pseudoephedrine behind the counter could make DXM less readily available. Some states already require purchasers of OTC cough and cold medications containing DXM to present an ID proving they are 18 or older. We believe this should become mandatory nationwide and that sellers of these drugs should be held accountable.

Furthermore, mass awareness campaigns targeting parents, teachers, law enforcement and counselors need to remind adults of the dangers of these drugs, whereas prevention programs for children and teens should increase their focus on the dangers of OTC medications. National campaigns and policy changes are called for, but these alone will not likely be enough to cause real change. True prevention efforts require work on multiple levels — from the policymakers in Washington to counselors and parents in local communities. Each of us has a part to play, and each can make a difference.

Where do teens hear about DXM?

In today’s era of prolific internet and social media use, teens have more access to the world than ever before. In past decades, peer pressure to use drugs was a huge concern. It was thought that susceptible teens would be influenced by their peers in the neighborhood and at school. This peer pressure occurred face to face.

Today’s teens still confront in-person peer pressure, but they now also face this pressure virtually. Peer influence can come not just from the local teens at school but from millions of teens across the world online. Many teens access the internet and find out about drugs of abuse, including how to get high on OTC cough and cold medications.

A quick search of popular sites such as YouTube can lead teens to videos that either warn of the dangers of DXM or encourage users to experience the high from it. Unfortunately, many websites include dosing recommendations and “tripping” suggestions for having a better experience of getting high.

For example, Reddit, one of the most popular social media sites around the world, has an estimated 430 million active users. Reddit consists of threads that allow its users to post about certain subjects and topics. These threads are like cybercommunities made up of members who hold similar interests. One of these threads, called “r/DXM,” has more than 31,500 users. This thread allows people a place to describe their DXM highs and the side effects. It also provides advice on how to minimize certain side effects such as nausea.

Other websites and cybercommunities such as Dextroverse.org and the Vaults of Erowid provide teens outlets to post about their DXM highs and get advice from other users on how to use the drug. The site DexCalc.com allows users to enter their weights and get a recommended dose for the “plateau” of high they want to achieve. Although many of these websites claim that their purpose is “harm reduction,” teens typically use these sites for suggestions and advice on the “safest” using pleasures. All of these websites are accessible to teens, and all of them are free to use.

Prevention efforts

Fifteen years ago, the FDA issued warning labels on OTC cough and cold medications aimed at making parents aware of the dangers of medicine abuse by teens. The Stop Medicine Abuse campaign launched nationwide in 2004, but clearly that campaign was not successful. More needs to be done to dissuade youth from abusing OTC drugs.

As counselors, we need to step to the front lines of true preventive efforts. This means that we need to know more about DXM (and other OTC medications), the reasons teens are using it, the ways teens are getting it and the most effective methods to prevent its misuse.

Getting parents involved is a good first step. Parents must know what to look for and how to talk to their teens about OTC drugs. Counselors need to get the message out to parents to be realistic and truthful when educating teens about DXM. Scare tactics do not work for many teens; in fact, they may make teens more curious about experiencing the outcomes for themselves. A better approach for prevention may be for parents, family members and other adults to increase the quality of their connection to and communication with youth.

Research shows that establishing consistent messages against drug misuse and having clear boundaries early on can be among the best prevention efforts for teen drug use. Simple steps, such as hiding medications and taking inventory, can also be effective. Most parents want to trust their teens, but having medications that contain DXM where teens can access them is not wise, and many parents are not aware of the dangers of DXM medications. OTC cough and cold medicine should be as securely stored as opioid prescriptions.

In addition, parents need to know what sites their teens are accessing online. A parallel line of defense involves checking browser histories and having clear rules about what teens can access online. Drug use is a leading cause of death among teens (resulting in more than 5,000 deaths per year according to figures from the National Institute on Drug Abuse). Parents wouldn’t want their teens searching for firearms or lethal poisons online, and no parent should want their teen searching for how to get high from DXM. Parents may not be comfortable with this advice. After all, it may feel like snooping, and teens are likely to resist as well. Even so, what teens access online can be one of the biggest telltale signs of drug use.

Establishing rules for computer/internet usage (e.g., allowing a teen to use the internet for two hours a day after completing homework), installing a firewall and setting locks or passwords for downloads can all be safety measures that contribute to prevention or, when needed, intervention. The earlier that parents establish household internet rules, the better. Proactive planning and putting rules in place before children reach their teen years may prove much easier than trying to establish new rules once teens are in late adolescence.

Talking to teens about drug use is often uncomfortable for parents. Many parents do not know where to begin. Some parents are worried that talking about drugs will increase their children’s curiosity about using. Other parents simply find the topic embarrassing or awkward. As counselors, we need to help parents develop communication skills with their children and teens, but especially starting in middle childhood. Counselors can provide parents with resources for where to find information about drugs of abuse, and we can intervene if a teen has already started using. It is almost a certainty that teens talk to other teens about getting high on OTC cough and cold medication. As counselors, we need to encourage parents to talk to their children about choosing not to get high on it.

If Sharon Davis, as both a counselor and parent, had recognized the signs of DXM abuse in her son, he might have gotten help sooner. The message we want parents and counselors to hear is that DXM is one of the most popular drugs for teens, and despite it being legal and easy to get, it is not safe when misused. Sharon was unable to prevent all the damage done to her son, but we hope that her story will help parents of children and teens across the country to protect their own sons and daughters.

 

****

Emily Weaver is a graduate student in the clinical mental health counseling program at Arkansas State University. She plans to graduate in the spring, become a licensed professional counselor and pursue a career in addictions counseling. Contact her at emily.weaver@smail.astate.edu.

Sharon J. Davis is a professor at Arkansas State University and a certified rehabilitation counselor. Contact her at sharondavis@astate.edu.

David Saarnio is a professor of psychology at Arkansas State University with a specialty in developmental psychology.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Integrating substance dependence and pain management into counseling approaches

By Geri Miller November 5, 2020

In the United Sates, 2000-2010 was labeled the “decade of pain.” In 2011, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education stated that the prevalence of chronic pain in our country exceeded the prevalence of diabetes, heart disease and cancer combined.

Unfortunately, this prevalence of pain has continued, and because of that, counselors need to be aware that substance dependence and pain management may be an issue for their clients — even if it is not a “problem” as presented by clients themselves. Clients may be particularly vulnerable to substance dependence specific to opioids because they (or others in their lives) may view these drugs as the best treatment for pain (i.e., a “quick fix”).

There is a great deal to know about substance dependence and pain management. Because of this, counselors can easily become overwhelmed and hesitate to work with these issues. I am writing this article to help counselors see that they can readily integrate some basic substance dependence and pain management approaches into their current counseling practices and still be practicing within their area of competence.

Because of the prevalence of substance dependence and pain management in the United States, it would serve counselors well to always “wear the lenses” of both of these areas as they assess and treat their clients. However, it is probably most important for counselors who are working with clients specifically on either one of these two areas (substance dependence or pain management) to also intentionally explore the area not presented as a problem so that the potential relationship between the two is examined. For example, when counseling someone who struggles with chronic pain, a counselor would be well advised to also ask about their substance use. The same exploration needs to happen when a client struggles with substance dependence; a counselor should ask about any issues with pain and its management.

While this exploration is important, it is also imperative for counselors to be able to readily fuse these “lenses” into their existing clinical approaches. Five suggestions on the general process of incorporating these two perspectives follow.

First, counselors need to accept the reality that there is a lot to know about substance dependence and pain management and make sure that they work within their area of competence. One method for exploring and addressing these areas with their clients (while still practicing in their area of competence) is to use the “HOW” approach. This acronym encourages counselors to be honest, open and willing to discuss substance dependence and pain management issues with their clients. For example, a counselor can be honest about not knowing much about the client’s experience of pain, be open to being educated about the client’s perspective and be willing to discuss the pain experience with the client.

Second, counselors can anchor their approach in the discussion with respect for and genuineness toward the client. This client-centered approach inherently invites the client’s story of their pain (including the ways they try to handle the pain, such as opiates).

Third, counselors can assess and treat the pain using their typical counseling approaches and continue reassessment throughout the treatment process. Counselors should operate as gatherers of information about the pain and, as appropriate, consult with others (e.g., mentors, supervisors, colleagues, medical professionals) concerning appropriate ways to address the pain.

Fourth, counselors need to be aware of countertransference related to their own and their loved ones’ experiences with pain management and substance dependence. An awareness of their countertransference can enhance counselors’ effectiveness in addressing these overlapping areas.

Finally, counselors need to work within the realistic resource limitations that both they and their clients experience. For example, both counselors and their clients have limitations on the amount of time, energy and money they can invest in learning about and addressing the issues of substance dependence and pain management. Maintaining such a realistic perspective can cultivate more humane and practical counseling interventions that will result in less frustration for both the counselor and client.

An overview of chronic pain

In 2011, as stated previously, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education reported that chronic pain exceeded the combination of diabetes, heart disease and cancer in terms of prevalence in the United States. These historical statistics, in which the current issues of substance abuse and pain management are anchored, underscore the likelihood that many of our counseling clients are experiencing chronic pain but have not mentioned it or its impact on their lives in session. This prevalence should serve as an invitation for counselors to discuss pain and pain management with their clients.

In 2019, Beth Darnall, a pain scientist and director of the Stanford Pain Relief Innovations Lab, summarized the following information on chronic pain in her book Psychological Treatment for Patients With Chronic Pain. By definition, chronic pain is pain that lasts longer than three months or that extends beyond the expected time it should take to heal. Breakthrough pain is an acute version of chronic pain and centers on days or times when the pain is worse.

Although Darnall called chronic pain a “harm alarm” that tells the person to escape the pain to survive, she said the “riddle of chronic pain” is that it is impossible to escape. This knowledge needs to be fused into the perspective of how the pain experience is affecting our counseling clients in a biopsychosocial manner. This biopsychosocial exploration of the relationship between the overlapping areas of substance abuse and pain management can be facilitated by the core suggestions presented in the following section.

Core suggestions

I offer seven core suggestions that counselors can use as a guide in addressing substance dependence and pain management from a biopsychosocial perspective.

1) Work out of a systems perspective. From this perspective, the counselor looks at the systemic interactions that result separately for addiction and pain, as well as their overlap systemically. This means that the counselor is aware of the internal and external contributing factors for both addiction and pain and that the client may have developed an addiction in response to their pain or vice versa. The addiction may have resulted from prescribed medication following surgery, or the pain may have resulted from an accident that occurred while the client was under the influence of alcohol or drugs.

2) Watch for prescribed and nonprescribed substance use. This suggestion means that the counselor obtains information from the client about any prescribed medication of substances (such as medication-assisted treatment) in response to their pain or substance dependence as well as the client’s nonprescribed usage of opiates and marijuana for pain. Such an inclusive gathering of information provides the counselor with a broader view of the client’s treatment responses to managing the pain.

3) Practice “compassionate accountability.” This phrase means that the counselor has compassion for the client and simultaneously holds the client accountable for their behavior. For example, I can have compassion that my client has an addiction resulting from their use of opiates in response to chronic pain that prevents the client from performing activities of daily living. However, I also need to hold the client accountable for their behavior, such as stealing prescription opiates from a friend’s medicine cabinet.

4) Use firm, direct, honest communication. This is complementary to exercising compassionate accountability because this form of communication avoids enabling behaviors related to both pain management and addiction. No matter what, clients are responsible for the choices they make, and counselors need to be clear with clients about what they see.

5) Consider a harm-reduction perspective. This perspective means that the counselor walks the fine line of not enabling the client’s substance use while at the same time not requiring the client to suddenly commit themselves to abstinence. Instead, the counselor works within the reality of the client’s willingness and ability to change without encouraging the client to remain at the same level of change.

6) Complete assessment and treatment plans for both addiction and pain. This involves the counselor examining both areas in a broad way that includes the client’s fear of the pain returning and their psychological withdrawal from pain medication.

7) Watch for behavioral indicators of pain during the session. A significant amount of information can be gathered when the client is actively experiencing pain. The client’s pain experience can be processed in the moment, and the resulting information can assist both the assessment and treatment processes.

Assessment

Counselors can use a simple anchoring assessment prompt to elicit each client’s story: “Tell me the story of your pain.”

That open-ended prompt has the power to draw out narratives that clients have perhaps not spoken about previously. These clients may be accustomed to closed questions or scaling questions regarding their pain, but they may never have had anyone ask about and then carefully listen to the actual story of their pain.

This motivational interviewing approach can readily draw out information about the impact of community, culture, family and multicultural factors on the individual’s self-report. For example, the client may talk about how pain is simply not discussed in their family and culture. As a result, they have learned not to reach out for support to address their pain. The counselor could then help the client develop skills to reach out to others who will be supportive of them as they live with their pain, or the counselor might refer the client to a group that discusses pain management approaches.

Another assessment approach is to have clients keep diaries or logs pertaining to their pain, sleep and nutrition. These logs can assist in obtaining information about pain patterns and contributing factors to pain. Such record-keeping also needs to focus on what the client is doing “right” as well as what they are doing “wrong,” in addition to times when the areas of pain, sleep and nutrition are going well for the client. The collection of this information is solution-focused and strength-based. It can become the cornerstone on which healing treatment is built.

The assessment of pain also needs to be considered within the context of addiction. So, although the client has pain, this does not mean that it is necessary for them to use substances to cope with that pain. Neither does the existence of pain prevent the client from being confronted about their addiction as a “stand-alone” diagnosis.

Thus, the message is twofold:

1) The client can learn to live with pain without the use of substances.

2) The client may need to be confronted solely on their use of substances.

Treatment

Treatment for pain can involve various therapy modalities such as individual, group or family counseling. The counselor and client can choose the modality that seems to best fit the needs of the client, in combination with the resources available related to client income, agency resources and community resources.

Specific therapy approaches can include motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and grief counseling (because when dealing with chronic pain, clients frequently have issues of loss). It is within these forms of therapy where clinicians can legitimately practice counseling in their areas of competence by simply anchoring themselves in their treatment approach (e.g., therapy modalities, specific therapy approaches) and adding the lenses of “pain” and “substance abuse” by asking about information in the assessment process that broadly addresses these areas. Such broad assessment can assist the counselor in knowing whether the treatment of pain and substance use can be readily integrated into treatment or whether a more specific assessment and focused treatment of these areas are required.

Treatments that change the client’s relationship with the pain by focusing on the present (e.g., mindfulness, yoga, biofeedback, acupuncture) are also potential resources. In such cases, clients may remain aware of the pain but work with the knowledge that the intensity of their pain ebbs and flows and learn how to live with that process. They may also find techniques to reduce their pain.

Another treatment approach, described by Kirsten Weir in 2017 in Monitor on Psychology, encourages the client to practice self-care of the body through diet, exercise and sleep. It uses the metaphor of a stool with three legs. I developed the diagram above for the fifth edition of my book Learning the Language of Addiction Counseling (currently in press) to illustrate this metaphor.

The three-pronged stool is precariously balanced, which illustrates that self-care is not a static entity but rather one that needs to fluctuate depending on the client and the context. Each leg of the stool (diet, exercise, sleep) is needed to keep the overall stool (self-care) in balance. In other words, each leg has an impact on the others. For example, the experience of pain may negatively affect a client’s sleep, which then inhibits them from exercising and tempts them to eat unhealthy comfort foods. In contrast, a client who gets enough sleep may experience diminished pain, thus encouraging them to exercise and practice healthy eating. Counselors need to remind clients, however, that “pretty good” self-care is good enough; one does not have to practice “perfect” self-care to reap the benefits.

A final treatment approach involves counselors viewing themselves as part of a health management team. Such a team can consist of different health care professionals in which each professional has an important perspective on the unique aspects of the individual client’s pain and pain management. The unique components of the client’s pain determine the composition of such a team and the treatment system in which the team exists (e.g., hospital setting, private practice). Whether the team is formally or informally established by the counselor or by the system in which the counselor works, the counselor provides a critical mental health perspective that is needed for a holistic treatment approach.

As part of such a team, counselors familiarize themselves with any prescribed medications that the client is taking for chronic, active disorders. Counselors then play a role in the planned and gradual reduction of medications being taken. Counselors do not need to be experts in pain management or medications to be part of such a team or to be assigned to a formal team. The team approach can be extremely effective in serving the welfare of clients.

The counseling perspective offers important contributions to such teams, including a heightened sensitivity for clients’ pain stories and a commitment to advocating for clients. Such a perspective can result in an effective and humane approach to pain management and the use of prescription drugs. Additionally, this perspective can prevent clients from feeling like they are being dehumanized on a “medical assembly line” during the treatment process.

Conclusions

Clinicians can work effectively with clients by integrating pain management and substance use approaches into their already-existing counseling approaches. Awareness of the prevalence of chronic pain and its potential interaction with substance use can assist counselors during the assessment and treatment process.

Chronic pain and substance use frequently overlap, but they are areas that can easily be missed in terms of their impact on clients’ presenting problems. Simply by integrating the lenses of pain management and substance use into their counseling — asking questions and intervening as necessary — clinicians can offer a more holistic approach to their clients.

The development of these lenses can be enhanced through continuing education, ongoing training and staying informed on current research. There are some excellent resources (see below) that counselors can add to their clinical toolboxes. Counselors who commit to more deeply examining the areas of pain management and substance use can improve their overall treatment effectiveness and, thus, act in the best interests of their clients.

Recommended resources

****

Learn more: ACA has produced a series of webinars with Miller on this topic. See more at ACA’s Professional Development Center: https://imis.counseling.org/store/catalog.aspx#

****

Geri Miller is a licensed professional counselor, licensed clinical addiction specialist, certified clinical supervisor, master addiction counselor, licensed psychologist, diplomate in counseling psychology and a professor in the Department of Human Development and Psychological Counseling at Appalachian State University. She has worked in the counseling profession since 1976 and in the addictions field since 1979. She has published and presented research on counseling, and the fifth edition of her book Learning the Language of Addiction Counseling is currently in press. Contact her at millerga@appstate.edu.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.